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Background: A substantial proportion of smokers nowadays smoke fewer than 10 cigarettes per day (cpd). These 'light' smokers are still exposed to significant health risks but may not receive as much attention from health professionals as heavier smokers. The Netherlands and England are two countries with very different smoking cessation treatment climates and may vary in the extent to which GPs advise on smoking cessation., Objectives: To assess whether Dutch and English light smokers (< 10 cpd) are less likely to receive advice to stop smoking during a consultation with their GP than moderate-to-heavy smokers (≥ 10 cpd)., Methods: We compared data from two series of national surveys: the Dutch 'Continuous Survey of Smoking Habits' and the English 'Smoking Toolkit Study'. We included respondents to both surveys from February 2010 to December 2011, aged 16+ years, who consulted their GP in the previous 12 months., Results: A total of 7734 smokers responded to the surveys in the Netherlands and 10 383 in England. The percentage of Dutch smokers who received advice to quit from their GP was 22.6% (95% CI = 21.5-23.7) compared with 58.9% (95% CI = 57.6-60.2) of English smokers. Light smokers were less likely to receive advice to quit than moderate-to-heavy smokers, both in the Netherlands (OR = 0.57, 95% CI = 0.50-0.65) and in England (OR = 0.64, 95% CI = 0.57-0.72)., Conclusion: Smokers in the Netherlands are less than half as likely to receive advice to quit from their GP as smokers in England. In both countries, light smokers are less likely to receive advice to quit from their GP than moderate-to-heavy smokers.

Publishing research can be time consuming, as papers are often submitted and reviewed by multiple journals before final acceptance. We hypothesized that attaching previous peer-review reports to the next submission of the paper to a different journal (possibly with point-to-point responses and amendments) could decrease the workload for both reviewers and editors and could shorten the time from final draft to actual publication. We therefore performed an online survey to assess the views of the editors-in-chief of all 100 general medical journals from the citation impact factor report category "internal & general medicine" (ISI Web of Knowledge). Of contacted editors, 61% responded. One of 4 journals do currently receive peer-review reports on occasion. Editors recognized potential advantages but also concerns on using previous peer-review reports across 3 themes: scientific community, quality of papers, and the publication process. The use of previous peer-review reports has the potential to facilitate authors, reviewers, and editors in optimizing peer review in general medical science.

Background: A potential new treatment in smoking cessation and relapse prevention is nicotine vaccination which is based on active immunization against the nicotine molecule. This immunization will elicit the immune system to produce nicotine-specific antibodies that sequester nicotine in the blood stream, after inhaling tobacco products. The resulting antibody-antigen is too large to cross the blood-brain barrier and is therefore postulated to attenuate the rewarding effect of nicotine by preventing the latter from reaching its receptors in the brain and causing the release of dopamine. The aim of this paper is to describe the design of a phase IIb, multi-center, double blind, randomized, placebo controlled trial to assess the efficacy of the nicotine vaccine NicVAX® co-administered with varenicline (Champix®) and intensive counseling as an aid in smoking cessation and relapse prevention., Methods/design: Two centers will include a total of 600 smokers who are motivated to quit smoking. At week -2 these smokers will be randomized, in a 1:1 ratio, to either 6 injections of NicVAX® or placebo, both co-administered with 12-weeks of varenicline treatment, starting at week 0. The target quit day will be set after 7 days of varenicline treatment at week 1. Smokers will be followed up for 54 weeks. The primary outcome is defined as biochemically validated prolonged smoking abstinence from week 9 to 52. Secondary outcomes include safety, immunogenicity, smoking abstinence from week 37 to 52, abstinence from week 9 to 24, abstinence in the subset of subjects with the highest antibody response, and lapse/relapse rate., Discussion: This is the first study to assess the efficacy of a nicotine conjugate vaccine in combination with an evidence-based smoking cessation pharmacotherapy (varenicline) to quit smoking. Although NicVAX® is primarily designed as an aid to smoking cessation, our study is designed to explore its potential to maintain abstinence and prevent relapse. The results of this trial will give a unique insight in the potential of nicotine vaccination for relapse prevention., Trial Registration: ClinicalTrials.gov: (NCT00995033).

Expired-air carbon monoxide (CO) is often used to validate self-reported nonsmoking in clinical settings and research studies. It sometimes occurs that a person reports to have quit smoking, whereas the CO measurement classifies him/her as a smoker. This commentary summarizes possible explanations for this discrepancy and briefly discusses what to do when there is reason to believe that the CO measurement is incorrect.

Objective: To investigate whether smoke-free legislation in the Netherlands led to a decreased incidence of out-of-hospital sudden circulatory arrest (SCA). Smoke-free legislation was implemented in two phases: a workplace ban in 2004 and an extension of this ban to the hospitality sector on 1 July 2008., Design: Weekly incidence data on SCA were obtained from the ambulance registry of South Limburg, the Netherlands. Three time periods were distinguished: the pre-ban period (1 January 2002-1 January 2004), the first post-ban period (1 January 2004-1 July 2008) and the second post-ban period (1 July 2008-1 May 2010). Trends in absolute SCA incidence were analysed using Poisson regression, adjusted for population size, ambient temperature, air pollution and influenza rates., Results: A total of 2305 SCA cases were observed (mean weekly incidence 5.3±2.3 SD). The adjusted Poisson regression model showed a small but significant increase in SCA incidence during the pre-ban period (+0.20% cases per week, p=0.044). This trend changed significantly after implementation of the first ban (with -0.24% cases per week, p=0.043), translating into a 6.8% (22 cases) reduction in the number of SCA cases after 1 year of smoke-free legislation. No further decrease was seen after the second smoking ban., Conclusions: After introduction of a nationwide workplace smoking ban in 2004, a significant decrease in the incidence of out-of-hospital SCA was seen in South Limburg. Poor enforcement of the 2008 hospitality sector ban may account for the fact that no further decrease in the incidence of SCA was seen at this time.

Background: We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts., Objectives: The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers making a quit attempt., Search Methods: We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012., Selection Criteria: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers or both., Data Collection and Analysis: Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives., Main Results: We found eleven trials involving financial interventions directed at smokers and healthcare providers.Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI 1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per additional quitter ranging from $119 to $6450., Authors' Conclusions: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

Aims: There is a growing interest in very low rate [fewer than one cigarette per day (CPD)] and light (one to nine CPD) smokers and in some parts of the world their numbers appear to be increasing. This paper examined changes in prevalence over the past 5 years, cessation patterns, and smoking and demographic characteristics of very low rate, light and moderate-to-heavy (10+ CPD) smokers in England., Design: Cross-sectional and longitudinal data from aggregated monthly waves of a household survey: the Smoking Toolkit Study., Setting: England., Participants: A total of 23,245 smokers interviewed between November 2006 and May 2011 and 4147 who provided data at 6-month follow-up., Measurements: We compared the demographic and smoking characteristics between the three groups of smokers at baseline, and the rate of attempts to quit, use of aids to cessation and success of quit attempts at follow-up., Findings: Very low rate smoking remained extremely rare (1.9% of smokers in 2006 to 2.8% in 2011), but light smoking became increasingly common (23.9-32.8%). Compared with moderate-to-heavy smokers, very low rate and light smokers were younger, more often female and from a higher socio-economic background. They were more motivated to quit and enjoyed smoking less. During the 6-month follow-up period, light smokers, but not very low rate smokers, were more likely to attempt to quit than moderate-to-heavy smokers. When they tried to quit, very low rate and light smokers used aids to cessation less than moderate-to-heavy smokers but still used them to a substantial degree: 18%, 31% and 44% used over-the-counter nicotine replacement therapy in their most recent quit attempt for the three types of smoker, respectively. Even very low rate smokers had a substantial failure rate: 65% failed in their most recent quit attempt within 6 months., Conclusions: Very low rate (fewer than one cigarette per day) and light (one to nine cigarettes per day) smokers in England are at least as motivated to quit as heavier smokers. Although they use cessation medication less than heavier smokers and are more likely to succeed, they still use such medication and fail in quit attempts to a substantial degree., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Most studies on lung function heritability have been conducted in smokers and non-smokers using cross-sectional study design. Smoking patterns may, however, confound the contribution of genetic factors. We investigated heritability of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio longitudinally, excluding the effects of smoking. A sample of never smoking female twins (n = 374), aged 63-76 at baseline, answered health questionnaires and attended spirometry in years 2000 and 2003. Bivariate structural equation modeling, restricted to adequate spirometry performances (baseline n = 339, follow-up n = 252), was used to estimate genetic and environmental influences on consecutive measurements of FEV1, FVC, and FEV1/FVC. The best-fitting models included additive genetic and non-shared environmental effects. Heritability estimates of 32% and 36% for FEV1, 41% and 37% for FVC, while 46% and 16% for FEV1/FVC were found at baseline and at follow-up. Genetic correlation between FEV1 and FEV1/FVC heritability estimates approached unity, whereas correlation between FVC estimates was 0.80. Environmental correlations were 0.69 for FEV1, 0.62 for FVC, and 0.07 for FEV1/FVC. In never smokers, additive genetic and non-shared environmental effects explain the inter-individual variations in FEV1, FVC, and FEV1/FVC. One third of the variation in FEV1 and FVC is explained by genetic and two thirds by environmental effects. Between 2000 and 2003, environmental effects on FEV1/FVC changed, and the proportion of variance explained by environmental effects increased remarkably. Genetic effects on FEV1 and FEV1/FVC are common to consecutive measurements, whereas at follow-up, new genetic factors explained 14% of the observed variance in FVC.

Introduction: Varenicline has recently been added to the market as a new drug for smoking cessation. The aim of the current study was to assess whether varenicline substituted for, or added to, the use of other smoking cessation medications., Methods: We used data from 2,595 smokers taking part in monthly household surveys of representative samples of the English population. We analyzed the percentage of smokers attempting to quit in the past 3 months and using nicotine replacement therapy over the counter (NRT OTC), NRT on prescription (NRT Rx), bupropion, or varenicline from November 2006 to December 2009. This survey covered 3 periods: (a) after the launch of varenicline but before the publication of the National Institute of Health and Clinical Excellence guidance on varenicline in July 2007, (b) the first year following the guidance, and (c) more than 1 year after the guidance., Results: Varenicline usage was negligible in the first period, increased steadily during the second period, and increased less rapidly in the third period to 5.3% of those making a quit attempt (p < .001 for the trend). The percentage of quit attempters using any smoking cessation medication increased nonsignificantly by 2.8 percentage points from 41.7% to 44.5% (p = .268). The use of NRT OTC decreased significantly by 6.2 percentage points from 35.2% to 29.0% (p = .029), whereas the use of NRT Rx increased significantly by 3.7 percentage points from 6.8% to 10.5% (p = .025), and use of bupropion remained unchanged., Conclusions: Increased use of varenicline in England following guidance from the National Institute for Clinical Excellence in 2007 did not appear to substitute for use of other prescription smoking cessation medication. An observed decline in NRT OTC is likely to have been due to other factors.

This study aimed to test the much-pronounced but poorly supported theory that "Guinness does not travel well." A total of 4 researchers from 4 different countries of origin traveled around the world for 12 mo to collect data on the enjoyment of Guinness and related factors. The main outcome was measured on a Visual Analogue Scale (VAS) from 0 (enjoyed it not at all) to 100 (enjoyed it very much). A total of 103 tastings were recorded (42 in Ireland, 61 elsewhere) in 71 different pubs spread over 33 cities and 14 countries. The enjoyment of Guinness consumed in Ireland was rated higher (74 mm VAS) than outside Ireland (57 mm; P < 0.001). This difference remained statistically significant after adjusting for researcher, pub ambience, Guinness appearance, and the sensory measures mouthfeel, flavor, and aftertaste. This study is the first to provide scientific evidence that Guinness does not travel well and that the enjoyment of Guinness (for our group of nonexpert tasters) was higher when in Ireland. Results, however, are subject to further verification because of limitations in the study design.

Background: Previous descriptions of the epidemiology of peanut allergy have mainly been derived from small cross-sectional studies., Objective: To interrogate a large national research database to provide estimates for the incidence, prevalence, and trends of general practitioner (GP)-recorded diagnosis of peanut allergy in the English population., Methods: Version 10 of the QRESEARCH database was used with data from 2,958,366 patients who were registered with 422 United Kingdom general practices in the years 2001 to 2005. The primary outcome was a recording of clinician-diagnosed peanut allergy., Results: The age-sex standardized incidence rate of peanut allergy in 2005 was 0.08 per 1000 person-years (95% CI, 0.07-0.08), and the prevalence rate was 0.51 per 1000 patients (95% CI, 0.49-0.54). This translated into an estimated 4000 incident cases (95% CI, 3500-4600) and 25,700 prevalent cases (95% CI, 24,400-27,100) of GP-recorded diagnosis of peanut allergy in England in 2005. During the study period, the incidence rate of peanut allergy remained fairly stable, whereas the prevalence rate doubled. In those under 18 years of age, the crude lifetime prevalence rate was higher in males than females. A significant inverse relationship between prevalence and socioeconomic status was found., Conclusion: These data on GP-recorded diagnosis of peanut allergy from a large general practice database suggest a much lower prevalence in peanut allergy than has hitherto been found. This difference may in part be explained by underrecording of peanut allergy in general practice. Further research is needed to assess the true frequency of peanut allergy in the population and whether there has been a true increase in recent years., (Copyright © 2011 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.)

Background: Case-finding of chronic obstructive pulmonary disease (COPD) using spirometry may deter people with normal lung function from stopping smoking. The objective of this study was to observe the percentage of smokers screened with normal lung function that quit smoking., Methods: As part of a study on early detection of COPD, 518 smokers were screened with normal lung function (post-bronchodilator FEV(1)/FVC ≥ 70%). They were invited for a follow-up measurement after an average of 2.4 years. Non-smoking was validated by carbon monoxide (<10 ppm), and respiratory health related quality of life was measured with the Clinical COPD Questionnaire (CCQ)., Results: A total of 255 participants were followed up (49%). The point prevalence rate of non-smoking at follow-up was 18% (N = 47), and 9% assuming that all non-respondents were smokers. This rate was not lower than the expected rate of quitting in the Dutch population (8-9%) and primary "care as usual" in smokers screened with abnormal lung function (10%; p > 0.05 for all comparisons). The average decline in post-bronchodilator FEV(1) was 26 mL/year, which was unrelated to smoking status at follow-up. Non-smokers showed a clinically meaningful and statistically significant (p < 0.001) improvement in CCQ respiratory symptoms (-0.96) and total score (-0.51)., Conclusions: Our results do not suggest that early detection of airflow limitation to motivate smoking cessation reduces the rate of quitting in smokers shown to have normal lung function. Such smokers should be advised to quit smoking on the grounds that they are likely to improve their respiratory health in the short term and reduce their risk for smoking related diseases in the long term., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Questionnaires are often used in assessing health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). It is important that these questionnaires have good reliability, validity, and responsiveness. The aim of this study was to investigate and compare these properties in the disease specific Clinical COPD Questionnaire (CCQ) and the Chronic Respiratory Questionnaire self-reported (CRQ-SR)., Methods: Two hundred ninety six participants with spirometry confirmed mild to moderate COPD were included in a smoking cessation trial. It was assumed that health-related quality of life would improve in participants who stopped smoking. The questionnaires were administered at baseline and at weeks 5, 26, and 52 after the target quit date., Results: At baseline, 292 (97%) participants returned the CCQ and 296 (100%) the CRQ-SR questionnaire. For both instruments, the internal consistency was good (Cronbach's alpha >70%) as was the convergent validity with each other but not with spirometry. The CCQ was responsive to improvements in respiratory symptoms at both week 26 (-1.02, SD = 0.81) and 52 (-1.04, SD = 0.91) and in the total score at week 26 (-0.54, SD = 0.50) and 52 (-0.43, SD = 0.44). The mastery domain and the total score of the CRQ-SR were responsive at week 26 (1.14, SD = 0.82; 0.67, SD = 0.97 respectively) but not at week 52 (0.04, SD = 0.93; 0.38, SD = 0.57 respectively)., Conclusion: Both the CCQ and CRQ-SR are equally reliable and valid. The long-term responsiveness of the CCQ is better. Both questionnaires can be used in future studies involving patients with mild to moderate COPD. However, when the follow-up exceeds 26 weeks, the CCQ is the recommended alternative. Netherlands Trial Register: ISRCTN 64481813., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Aims: To assess factors associated with the use of smoking cessation aids among smokers trying to quit in a country where these aids are widely available and free or cheap to access., Design: Cross-sectional household survey, the 'Smoking Toolkit Study'., Setting: England., Participants: A total of 3767 respondents who smoked and made at least one serious quit attempt in the past 12 months were interviewed from November 2006 to April 2008., Measurements: We analysed differences across socio-demographic and smoking characteristics in the use of nicotine replacement therapy (NRT) over the counter or on prescription, bupropion, varenicline, telephone support and the National Health Service Stop Smoking Service (NHS-SSS) which combines behavioural support with medication., Findings: More than half of smokers trying to quit (51.2%) had used any kind of treatment; 48.4% had used some form of medication but only 6.2% had used the NHS-SSS. The use of some form of smoking cessation treatment was higher in female than in male smokers [odds ratio (OR): 1.24, 95% confidence interval (CI): 1.08, 1.43] and increased with age (OR: 1.19, 95% CI: 1.14,1.25) and cigarettes smoked per day (OR = 1.05, 95% CI = 1.04,1.06). There was no association with social grade. Smokers who planned their quit attempt were more likely to have used all types of smoking cessation treatments, except for telephone support., Conclusions: In England, half of all attempts to quit smoking are aided by some form of pharmacological or behavioural treatment. However, the use of the most effective treatment option (the NHS-SSS) is low, despite it being free of charge. Factors associated with an increased use of aids to cessation were female sex, older age, more cigarettes smoked per day and planning a quit attempt. Research is needed into how to increase utilization rates, particularly among males and younger smokers.

Objective: Within the framework of a randomized, active treatment controlled trial, we used a mediation analysis to understand the mechanisms by which an intervention that uses confrontation with spirometry for smoking cessation achieves its effects., Methods: Participants were 228 smokers from the general population with previously undetected chronic obstructive pulmonary disease (COPD), who were detected with airflow limitation by means of spirometry. They received two equally intensive behavioural treatments by a respiratory nurse combined with nortriptyline for smoking cessation: confrontational counselling with spirometry versus conventional health education and promotion (excluding confrontation with spirometry and COPD)., Results: Cotinine validated abstinence rates from smoking at 5 weeks after the target quit date were 43.1% in the confrontational counselling group versus 31.3% in the control group (OR=1.67, 95%CI=0.97-2.87). The effect of confrontational counselling on abstinence was independently mediated by the expectation of getting a serious smoking related disease in the future (OR=1.76, 95%CI=1.03-3.00), self-exempting beliefs (OR=0.42, 95%CI=0.21-0.84), and self-efficacy (OR=1.38, 95%CI=1.11-1.73)., Conclusion: We conclude that confrontational counselling increases risk perceptions and self-efficacy, and decreases self-exempting beliefs (risk denial) in smokers with previously undetected COPD. These changes in mediators are associated with a higher likelihood of smoking cessation., Practice Implications: Apart from the intensity, the content of smoking cessation counselling may be an important factor of success. A confrontational counselling approach as we applied may have the potential to alter smoking-related cognitions in such a way that smokers are more successful in quitting. Nurses can be trained to deliver this treatment.

Background: Elevated circulating levels of C-reactive protein (CRP), interleukin (IL)-6 and fibrinogen (FG) have been repeatedly associated with many adverse outcomes in patients with chronic obstructive pulmonary disease (COPD). To date, it remains unclear whether and to what extent systemic inflammation is primary or secondary in the pathogenesis of COPD. The aim of this study was to examine the association between haplotypes of CRP, IL6 and FGB genes, systemic inflammation, COPD risk and COPD-related phenotypes (respiratory impairment, exercise capacity and body composition)., Methods: Eighteen SNPs in three genes, representing optimal haplotype-tagging sets, were genotyped in 355 COPD patients and 195 healthy smokers. Plasma levels of CRP, IL-6 and FG were measured in the total study group. Differences in haplotype distributions were tested using the global and haplotype-specific statistics., Results: Raised plasma levels of CRP, IL-6 and fibrinogen were demonstrated in COPD patients. However, COPD population was very heterogeneous: about 40% of patients had no evidence of systemic inflammation (CRP < 3 mg/uL or no inflammatory markers in their top quartile). Global test for haplotype effect indicated association of CRP gene and CRP plasma levels (P = 0.0004) and IL6 gene and COPD (P = 0.003). Subsequent analysis has shown that IL6 haplotype H2, associated with an increased COPD risk (p = 0.004, OR = 4.82; 1.64 to 4.18), was also associated with very low CRP levels (p = 0.0005). None of the genes were associated with COPD-related phenotypes., Conclusion: Our findings suggest that common genetic variation in CRP and IL6 genes may contribute to heterogeneity of COPD population associated with systemic inflammation.

Chronic obstructive pulmonary disease (COPD) is associated with high personal and societal burden and mortality. COPD is usually diagnosed during middle or late adult life, but the starting point for a 'COPD career' may be found earlier in life, during adolescence: first, because of smoking initiation and subsequent accumulation of risk, and second, because of the adverse effects of cigarette smoking on lung-function development. The objective of this paper is to systematically review the literature on the effects of active smoking on lung health in 12-25-year-old healthy boys and girls, measured with simple and noninvasive methods: lung function by spirometry, exhaled gases (including nitric oxide, carbon monoxide and hydrocarbons) and exhaled breath condensate. The identification of biomarkers may be useful for early detection of tobacco-related respiratory disease in this population, for targeted smoking prevention or smoking-cessation programs and, in the long term, for a reduction of personal and societal impact of COPD and other smoking-related diseases.

Background: The use of spirometry for early detection of chronic obstructive pulmonary disease (COPD) is still an issue of debate, particularly because of a lack of convincing evidence that spirometry has an added positive effect on smoking cessation. We hypothesise that early detection of COPD and confrontation with spirometry for smoking cessation may be effective when applying an approach we have termed "confrontational counselling"; a patient-centred approach which involves specific communication skills and elements of cognitive therapy. An important aspect is to confront the smoker with his/her airflow limitation during the counselling sessions. The primary objective of this study is to test the efficacy of confrontational counselling in comparison to regular health education and promotion for smoking cessation delivered by specialized respiratory nurses in current smokers with previously undiagnosed mild to moderate airflow limitation., Methods/design: The study design is a randomized controlled trial comparing confrontational counselling delivered by a respiratory nurse combined with nortriptyline for smoking cessation (experimental group), health education and promotion delivered by a respiratory nurse combined with nortriptyline for smoking cessation (control group 1), and "care as usual" delivered by the GP (control group 2). Early detection of smokers with mild to moderate airflow limitation is achieved by means of a telephone interview in combination with spirometry. Due to a comparable baseline risk of airflow limitation and motivation to quit smoking, and because of the standardization of number, duration, and scheduling of counselling sessions between the experimental group and control group 1, the study enables to assess the "net" effect of confrontational counselling. The study has been ethically approved and registered., Discussion: Ethical as well as methodological considerations of the study are discussed in this protocol. A significant and relevant effect of confrontational counselling would provide an argument in favour of early detection of current smokers with airflow limitation. Successful treatment of tobacco dependence in respiratory patients requires repeated intensive interventions. The results of this study may also show that respiratory nurses are able to deliver this treatment and that intensive smoking cessation counselling is more feasible., Trial Registration: : Netherlands Trial Register (ISRCTN 64481813).

Study Objectives: To assess and compare the smoking cessation practices and smoking behavior of Dutch general practitioners (GPs), cardiologists, and lung physicians., Methods: We conducted questionnaire surveys among a random sample of 2000 Dutch GPs, all Dutch cardiologists (N=594), and all Dutch lung physicians (N=375)., Results: In total, 834 GPs (41.7%), 300 cardiologists (50.5%), and 258 lung physicians (68.8%) filled out and returned the questionnaire. The prevalence of current smokers was 8.2% among GPs, 4.3% among cardiologists, and 3.5% among lung physicians. Of the pharmacological aids for smoking cessation, physicians recommended bupropion most frequently, followed by nicotine patches and nicotine gum. More lung physicians recommended the use of these three aids (67.0%, 36.3% and 18.2%, respectively) than GPs (65.7%, 18.7% and 9.8%, respectively), and than cardiologists (31.6%, 19.7% and 13.2%, respectively). A higher proportion of lung physicians (69.3%) had referred at least one smoker to a nurse for smoking cessation treatment than cardiologists (25%), and than GPs (11.3%)., Conclusions: Based on this national survey, one may conclude that the prevalence of current smoking among Dutch physicians is relatively low and has further decreased since 1988. Dutch GPs, cardiologists, and lung physicians mainly use interventions for smoking cessation that are easy to administer and are not very time consuming. Furthermore, more lung physicians than GPs and cardiologists recommend the use of bupropion, nicotine patch, and nicotine gum. When designing interventions for smoking cessation, one should take into account that physicians are often reluctant to provide interventions which demand much time. Therefore, intensive counseling of smokers who want to quit smoking may be more feasible for trained non-physicians, such as nurses.